Provider Demographics
NPI:1740361450
Name:FEDO ROSVOLD, SUSAN MARIE (MA CCC SLP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:MARIE
Last Name:FEDO ROSVOLD
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MARIE
Other - Last Name:FEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC SLP
Mailing Address - Street 1:801 BROADWAY N
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-3641
Mailing Address - Country:US
Mailing Address - Phone:701-234-6970
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-6970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI770154235Z00000X
MN5815235Z00000X
ND1333235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42707900Medicaid
MNENROLLEDMedicaid
WI42707900Medicaid